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Aleutian Pribilof Islands Association, Inc.Human Services DepartmentEmployment, Training, & Related Services Division1131 East International Airport RoadAnchorage, AK 99518907-276-2700 or 1-800-478-2742Fax 907-222-9711Application for Services1. Please Select ALL Services You are Requesting – (Check ALL that apply to your immediate needs.)Direct Assistance Programs: Energy Assistance General Assistance Adult Care Assistance Child Assistance Disaster Assistance Emergency Assistance Burial Assistance Child Care AssistanceTo Process your application for Direct Assistance, please include the following: *A completed Application for Services including signatures and all questions answeredRelease of Information section signed and datedTribal Card (For Burial Assistance, include Tribal Card of Deceased)Proof of wages for the last 30 days or attached Section 9 of this application completed by your employer.Rent or Mortgage Receipt (ALL Programs EXCEPT Energy Assistance, Burial Assistance & Child Care Assistance)Bank Statement (ALL Programs EXCEPT Energy Assistance & Burial Assistance)W-9 (ALL Programs EXCEPT Energy Assistance & Burial Assistance)Child Care Assistance: Please fill out ONLY Sections 1, 2 & 3 of this applicationEmployment & Training Programs: Job Placement & Training Assistance Employment Services AANG Program – Tribal Vocational Rehabilitation Higher Education Youth Employment ProgramTo Process your Employment & Training application, please include the following: A completed Application for Services including signatures and all questions answered Release of Information section signed and dated Tribal Card Proof of wages for the last 30 days or attached Section 9 of this application completed by your employer. W-9* Higher Education: Enrollment Verification, Class Schedule, Budget Forecast from Financial Aid Office, Proof of FAFSA Application* Higher Education: Applications are DUE December 15 for Spring Semester courses & June 15 for Fall Semester coursesTo report FRAUD or ABUSE of Energy Assistance funds, please call APIA’sETR Division of the Human Services Department at907-276-2700 or toll free at 1-800-478-2742Where Can I apply?Completed applications and all supporting documents need to be mailed, faxed or dropped off at the following locations:All Other Communities:APIA1131 E InternationalAirport Rd.Anchorage, AK 99518Fax: 907-222-9711Unalaska:APIA179 Gilman Rd, Suite 209P.O. Box 1130Unalaska, AK 99685Fax: 907-581-6574Sand Point:APIA(City Building, #9)P.O. Box 464Sand Point, AK 99661Fax: 907-383-5832King Cove:APIA(Old School)P.O. Box 353King Cove, AK 99612Fax: 907-497-4181When Can I apply?Completed applications including all supporting documents for Energy Assistance will be accepted beginning October 1,2015. Higher Education applications are due by December 15th for the Spring Semester and June 15th for the Fall Semester.Applications for ALL other services can be turned in year-round.How long will my application take to process?It may take up to 30 days to process your application.Date Application Mailed or Faxed to APIA:
2. It is important that you tell us about your situation, your needs, and how we may assist you.3. Required Information for ALL ServicesFirst NameMiddle NamePhysical AddressLast NameCityStateZipMailing Address (If Different)Tribal Affiliation Agdaagux Atka Akutan Belkofski False PassSocial Security NumberDate of BirthEmail AddressHome/Message Phone Nelson LagoonNikolskiPauloff HarborQagan TayagunginQawalanginSt. GeorgeSt. PaulUngaOther:Cell PhoneWho can we contact if we cannot reach you at the number above?Name: Phone Number:4. Other Household Members - List all persons living in your household at time of applicationName (First, M.I., Last)Relation toApplicantDate of BirthAlaska Native orAmerican IndianSocial Security Number Yes NoSELF Yes No Yes No Yes No Yes No Yes No Yes No5. Applicant InformationHighest Level of Education Completed: 8th Grade or Below 9th Grade 10th GradeMilitary Experience: Current Active Duty Reserves 11th Grade 12th Grade GED Some College College Graduate Vocation/Technical SchoolVeteranDisabled Veteran2 National Guard None
Have you registered for selective service?Do you hold a valid driver’s license? Yes No Yes NoAre you currently employed (If yes, please explain below): Yes NoEmployer Job Title Full Time Part TimeHow long have you been with your current or previous employer Years MonthsHave you ever been convicted of a crime (If yes, please explain below): Yes NoDate OffenseAdditional InformationAre you challenged with a disability or medical condition that creates a barrier to employment or accessingtraining? Yes No6. Household Shelter Expenses (Last 30 Days)RentWater Mortgage(Payment/Taxes/Insurance) Sewer Electricity Telephone (Cell) Heating(Household Oil/Fuel/Wood)Other:Telephone (Landline) Other: Medical/DentalLegal Dues (Fines, Fees, Court Costs, etc.) Other Monthly Expenses (Last 30 Days)Vehicle Payment Gas for Vehicle Vehicle Insurance Prior Tax Payments Child Support/Alimony Student LoansEntertainment(Movies, Bingo, etc.)Cable TV/InternetOther: Other: Food (Groceries, Dining Out) Personal Hygiene Clothing Other: 7. Asset InformationChecking Account (current balance) Savings Account (current balance) If you have no income, please provide a written statement as to how you supported yourself and your family in thelast 30 days. This will serve as your income statement. Please be as detailed as possible.3
8. Household Income Without proof of income, your application may be delayed or denied. Acceptable proof includes wage stubs showingcheck date, gross income, year-to-date figures, an employer statement (Form A) or signed letter from your employer.Year-end statements or award letters are required for Social Security and retirement benefits. Provide ALL GROSS income (before taxes) and ALL income received in the last 30 days for your entire HOUSEHOLD. You must provide proof of income and attach it to the application. If you are applying for Burial Assistance, please fill out household income for the deceased.SOURCE OF INCOME & RESOURCESAMOUNTSalary # 1: Applicant's Income/Salary Salary # 2: Spouse's Income/Salary Salary #3: Adult Household Member Salary Salary #3: Adult Household Member Salary Child Support / Alimony Foster Care Payments AK Temporary Assistance Program (ATAP) Temp Assistance for Needy Families (TANF) Adult Public Assistance (APA) Social Security - Retirement (SSA) Supplemental Security Income (SSI) Disability Insurance (SSDI) AK State Permanent Fund Dividend (PFD) Retirement or Pension Plan Payments Annuity Payments Unemployment Insurance Benefits Worker's Compensation Tips or Gratuities State Longevity/Elder Assistance Veteran's Benefits Food Stamps Medicare / Medicaid Native Corporation Dividends Other Tribal Assistance Student Loans / Grants / Scholarships Bingo or Pull Tab Winnings TOTAL MONTHLY INCOME 4
APIA 1131 E International Airport Rd. Anchorage, AK 99518 Fax: 907-222-9711 Unalaska: APIA 179 Gilman Rd, Suite 209 P.O. Box 1130 Unalaska, AK 99685 Fax: 907-581-6574 Sand Point: APIA (City Building, #9) P.O. Box 464 Sand Point, AK 99661 Fax: 907-383-5832 King Cove: APIA (Old School) P.O. Box 353 King Cove, AK 99612 Fax: 907-497-4181
